HomeMy WebLinkAboutSeptic Pumping Slip - 107 LIBERTY STREET 11/22/2016 Commonwealth of Massachusetts
= City/Town of NORTH ANDOVER
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information RECEIVED
Important:When 1. System Location: mm(. U 'I Z
filling out forms fj
on the computer,
use only the tab 107 LIBERTY STREET
key to move your Address
cursor-do not NORTHANDOVER MA HEALTH I)Er%q,4,,
use the return
key. Cit y/Town State Zip Code
2, System Owner:
reb LUIS CARRILLO
Name
Address(if different from location)
State Zip Code
Telephone Number
B. Pumping Record
11/22/16 1500
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank F-1 Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER 11 H79 406
Name Vehicle License Number
XSEPTIC & DRAIN
Company ----
7. Location where contents were disposed:
GLSID
11/22/16
.........
Sig 4tur-e—of H'au'ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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